Download Atherosclerotic coronary vascular disease

Atherosclerotic coronary vascular
disease
• ASYMPTOMATIC ~ 50 %
• SYMPTOMATIC ~ 50 %
• ISCHEMIC HEART DISEASE = ANGINA
Increased CV risk( MI)for
dentistry
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EXTREME
Recent MI
Unstable angina
Uncompensated CHF
Significant arrhythmias ( ventricular)
Severe valvular disease
– AHA. 2002. Circulation. 105:10.
Increased CV risk( MI) for
dentistry
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MODERATE
previous MI
ANY angina
ANY CHF ( walking flight of stairs)
ANY arrhythmias
IDDM
CVA
Renal disease
HTN
-AHA. 2002. Circulation. 105:10.
Advanced age
Atherosclerotic coronary vascular
disease
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RISK FACTORS
age and sex
genetics; family history
serum lipid levels
HTN
tobacco ( smoking)
elevated blood glucose
Atherosclerotic coronary vascular
disease
• RISK FACTORS :
• cigarette smoking : 2- 6 X CVD than nonsmokers ( degree and duration dependent)
• increased risk of complications: angina, MI,
cardiac arrest
• Framingham study: >5000 smokers; 5 -year
death rate = 22 % smokers; 15% if
discontinued
Modifying risk factors
• 400,000 patients without smoking,
cholesterol or HTN risk
• 75-88% decrease in risk of adverse CVD
• 48-58 % decreased mortality risk
• Additional 5.8 - 9.2 years of life
• Stamler J, et al. JAMA. 1999; 282:2012-2018.
HMG COA REDUCTASE
INHIBITORS
Drug
Strengths Equipotent Daily Monthly
Dosage
Dose Cost $
Fluvastatin
(Lescol)
Lovastatin*
(Mevacor)
Pravastatin*
(Pravachol)
Simvastatin
(Zocor)
20, 40
20
20-80
34 -77
10, 20, 40
10
10-80
37-234
10, 20, 40
10
10-40
53-96
5, 10, 20,
40
5
5-40
53-106
Use of HMg COAs can reduce cholesterol by 35%. * Should not be
used with certain drugs
ANGINA PECTORIS
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initial; exertional or at rest; LEVEL
STABLE vs. PROGRESSIVE
FREQUENCY- SEVERITY- CONTROL
brief chest pain ( 1-3 minutes)
ususally size of fist in mid-chest
aching, squeezing, tightness
may radiate, left shoulder, arm, mandible,
palate, tongue
ANGINA PECTORIS
• DENTAL OFFICE
• STRESS, ANXIETY, FEAR>>>> release of
endogenous epinephrine>>> increased HR,
BP( HR x MAP > 12,000 !!) >>> increased
cardiac load, O2 demand>>> additional
epinephrine ( LA) >>> exacerbated angina
ISCHEMIC HEART DISEASE
• PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY ( PTCA)
• insertion of catheter to “clean out” and
widen occluded vessels
• invasive!! complications = thrombosis,
emboli, arrhythmias
• induces MI = 1%; CVA= 1%; death= 1%
• minor complications = 5-10%
ISCHEMIC HEART DISEASE
• PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY ( PTCA)
• RESULTS:
• 85-90 % relief of angina
• in 25 % of cases angina returns to previous
level within 6-12 months
• if no recurrence of angina/stenosis > 1 yr.=
EXCELLENT PROGNOSIS
ISCHEMIC HEART DISEASE
• PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY ( PTCA)
• balloon angioplasy
• balloon angioplasy + STENT
ISCHEMIC HEART DISEASE
• Coronary artery bypass graft ( CABG)
• indicated with 2 > occluded coronary
arteries (proximal obstruction)
• most common left anterior desending c.a.
• complications ; death = 1%
• vein grafts occlude to previous level
10% within 1st year; 2 % per year
afterwards, depending on lifestyle
ISCHEMIC HEART DISEASE
• post-CABG 5-yr. mortality = 50 %
• RESULTS : complete relief = 60 %
partial relief = 20-30 %
no relief = 10 %
• use sapphenous vein;
• currently no synthetic material
• re-op: limited ; maybe int. mammary a.
DENTAL MANAGEMENT for
ANGINA PECTORIS
• mild
diagnosed, monitored
infrequent symptoms
use NGN <2 x week; exertion only
easily controlled
• moderate
diagnosed, ± monitored
occasional symptoms
use NGN <5 x week; exertion
easily controlled
DENTAL MANAGEMENT for
ANGINA PECTORIS
• severe
diagnosed, ± monitored
± frequent symptoms
use NGN <8 x week; exertion
not necessarily well controlled
DENTAL MANAGEMENT for
ANGINA PECTORIS
• mild
most dental tx vitals, sedation
• moderate simple tx
vitals, sedation ±
prophylactic NGN
vitals, sedation +
routine tx prophylactic NGN
complex tx HOSPITALIZATION
• severe
simple tx
vitals, sedation +
prophylactic NGN
routine-complex tx HOSPITALIZATION
ISCHEMIC HEART DISEASE
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MYOCARDIAL INFARCTION
Approx. 550,000 deaths per year in U.S.
20 % sudden death( <2 hrs.) from MI
ASCVD>>>occlusion>>>anoxia>>>
ischemia>>>infarct>>>necrosis
• PAIN : longer and more severe than angina
• same location, character, pattern, radiates
• not relieved by nitrates or rest
Prognosis After Infarction
• Hospital discharge after 7 days
• 50% of survivors are at increased risk of
further cardiac events
• Without further treatment, 5-15% will die in
first year; similar number will have
reinfarction
• With treatment, morbidity and mortality
markedly reduced (<3% in GUSTO trial)
MYOCARDIAL INFARCTION
• history of past -MI
• best to wait >6 months= NO ROUTINE
CARE! If so, AHA prophylaxis
• physical status, Rxs, vital signs, fatigue,
CHF, cardiac reserve
• CLOSE MONITORING !!
• MEDICAL CONSULTATION
MYOCARDIAL INFARCTION
• short, non-stressful appointments schedule
at BEST time for patient
• changes>>>> STOP- POSTPONE dental tx
sedation : N2O2
• good anesthesia, pain control, anxiety
reduction, etc.
• prophylactic oxygen ( nasal cannula) ±
NGN; ALWAYS have NGN available!
MYOCARDIAL INFARCTION
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NO EPINEPHRINE
anticoagulants( Coumadin)
PT or INR, BT
arrhythmias
CHF
Rxs: side-effects, interactions, adjustment
MYOCARDIAL INFARCTION
• short, non-stressful appointments schedule
at BEST time for patient
• changes>>>> STOP- POSTPONE dental tx
sedation : N2O2
• good anesthesia, pain control, anxiety
reduction, etc.
• prophylactic oxygen ( nasal cannula) ±
NGN; ALWAYS have NGN available!